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NFL is here, which means no matter where you are, this is how you football. Live out of market preseason games, live local and primetime regular season games on your phone or tablet, 45 minute game replays and more. This is the NFL for every fan. This is football freedom. This is your game on the go wherever you are. This is how you football. Go to plus.nfl.com/radio and start your free trial of NFL Plus today, terms and conditions apply. From the New York Times, I'm Michael Barbaro. This is the daily. Today. A Times investigation finds that surviving the coronavirus in New York had a lot to do with which hospital a person went to. My colleague, investigative reporter Brian Rosenthal on inequality and the pandemic. It's Monday, July 27th. Thank you for being here today. This is an amazing accomplishment. Strategy plan of action all along. Step one, flatten the curve. Step 2, increase hospital capacity. That's what this is all about, not overwhelming her hospital capacity and at the same time increasing the hospital capacity that we have. So if it does exceed those numbers, which it will in most probability. That we have the additional capacity to deal with it. Brian, you have been part of a team investigating how the coronavirus was handled in New York City, and I'm curious why you undertook this project. My sense is that New York has done a fairly solid job flattening the curve over the past few months. So what was your aim? So New York was clearly the first big hot spot for the coronavirus in the United States and yes, we did succeed in flattening the curve, but we also experienced a lot of tragedy along the way, a lot of death and a lot of heartbreak and now that the rest of the country is going through. Different sources in the virus and different versions of what we went through in March and April. I think it's really important to look at the experience in New York, the successes that were had, but also the mistakes that were made and if you look at what happened in hospitals in New York. In a real close way, you'll see that there were a lot of mistakes and as a result people died. And where does that story start in your reporting when the pandemic began in New York, a team of us on the metro desk. Really were trying to follow what was happening. And we realized very quickly that there was no one story about how this was playing out in hospitals because there are 47 different hospitals in New York City and each one was having its own experience. So a team of us divided them. Some of us took the public hospitals, some of us took more of the private hospitals, and we started calling doctors nurses. Physician assistants, all kinds of workers in each of those hospitals. And Brian, why does that distinction matter, public and private? Well, the public hospitals are the hospitals that are run by the government, and they cater mostly to residents who have Medicaid or Medicare or don't have any insurance at all. And the private hospitals are kind of the more elite institutions that we might be familiar with. Sinai and why you even go and Columbia, Cornell. And they cater mostly to wealthier residents with health insurance through their employer or purchased privately and after you talked to doctors and nurses and staff from all these different hospitals, both the public and the private. What did you learn? We found significant differences between the level of care available at these wealthy private hospitals, mostly in Manhattan, and the public hospitals and small independent hospitals scattered throughout the other boroughs. There were differences in basically everything once you walk in the door, but the biggest differences were in staffing, the level of. Nurses and doctors and other types of staff that were available on a per patient basis, as well as the equipment that was available, the aids of the equipment, the type of the equipment and access to drug trials and experimental treatments and advanced treatments that cost a lot of money and may not necessarily always work, but give the patients a fighting chance. Those are available much more in the private hospitals. Then the public hospitals tell me about the staffing ratios. Yeah. So the staffing ratio is very important in whether patients live or die. Research has shown that and there are some best practices that have been established through the years. If you look at an emergency room, for example, the best practice is that there's to be 4 patients for every one nurse, so that way the nurse is not. Having too many patients that they were trying to monitor and we were able to collect numbers showing the ratios in emergency rooms at private hospitals versus public hospitals. And you could see that the ratio is increased at every hospital, but at the private hospitals, while the ratio went up to one nurse for six or seven patients, it went up at the public hospitals to one nurse. For 10 or 15 or even 20 patients. So about twice, yeah. And in the ICU, the general ratio is because the patients are so severe, it's two patients for every nurse. And again, those ratios got stretched at every hospital in the city, but in private hospitals it would be stretched to three or four patients for every nurse. And in the public hospitals it was getting stretched to 789 patients for every nurse, which was obviously. Very dangerous. And what did the staff you talked to say were the consequences in some of these public hospitals? What did that translate into during the pandemic? It meant that doctors and nurses have less time to spend with each patient in public hospitals to. See how they were doing to talk with them, to run tests, and perhaps most importantly just to monitor them. Almost all of them won ventilators and really needed to be constantly monitored. One of the things that we've learned with the coronavirus is that patients can deteriorate very quickly. They can. Seemed like they were doing fine one minute and the next minute they could be going into cardiac arrest and at the understaffed public hospitals. We even heard some cases of patients waking up from medically induced comas, finding that there were no nurses around and in their confusion, actually removing. Their life supports and dying. Wow. It was something that was a pattern, somewhat of a pattern that at Elmhurst Hospital. That overwhelmed hospital that received a lot of attention. This happens so often with somebody woke up confused and removed the life support because they needed to go to the bathroom and they collapsed and they would discovered either in the bathroom or near the bathroom. Some of the doctors, they were actually developed a name for it. They called them bathroom codes and in those cases the patients would discovered you know, half an hour later. 45 minutes later by doctors and nurses who were devastated because if there had been staff there monitoring them, they would have been cared for. But instead, a nurse was doing the rounds for 15 or 20 other patients. That's right. And every case that we heard about, at least four cases at Elmhurst Hospital, the patients died. How else did the people you talk to in these hospitals tell you that staffing impacted mortality? Well, another example is something called Froning. Which is quite simply flipping a patient on their stomach, and it was something that very quickly, during the pandemic, doctors realized that. If they did, if they flip patients on their stomach, it would help the patient breathe and could be a useful tool in helping them recover. And so that was something that was used a lot in New York in private hospitals. But unfortunately in public hospitals there was not the staffing available to do it. Well, it turns out that. Pruning, just flipping someone on their stomach can actually be quite complicated if they have a bunch of IV lines and tubes running through them and it can require a five or six people to coordinate all the movements and make sure those lines are still running while flipping the patient. So it seems very simple and the doctors knew that it would help, but in some of those public hospitals they would not able to do it because they did not have. The staff available. One doctor at a small independent hospital told us that out of 10 of the deaths that he witnessed, he thought two or three of the patients could have been saved. If there had been better staffing, yeah, if the hospital had the resources of a private hospital. Wow. I mean that's 20 to 30%. Yeah, I mean it translates to thousands of people and we actually looked at the mortality rates at most of the 47 hospitals in the city. And in some cases the mortality rate was three times higher in the public hospitals in the lower income areas. Some of that mortality difference could be explained by differences in patient populations, you know, underlying health conditions of the patients. But the experts and the doctors that we talked to said that the quality of care was definitely a factor in those differences. Brian is horrible as everything you're describing is, it feels like there's a pretty logical solution to it, which is taking. COVID-19 patients from these overburdened, understaffed public hospitals and transferring them to the less burdened, better staffed private hospitals. You'd think that yes, and Governor Cuomo even said at the peak of the pandemic that that was going to happen. How many beds will you need at the apex? Between 70 and 110,000? Right now, we have. 53,000 statewide. We have only 36,000 downstate. Every hospital by mandate has to add a 50% increase and they have all done that. We're setting up extra facilities which but in the end it didn't and why not? Like, what prevents a patient at Elmhurst Hospital in Queens from being transferred to NYU Langone, which happens to be on the east side of Manhattan? It's not that far. Well, Elmhurst is a public hospital, and for decades they have not really transferred patients to NYU lingo, and they've transferred patients to other hospitals within the public system. But they just don't really. Work together with. The private system. So there's no infrastructure? Set up to make such transfers and therefore they're unlikely to happen. Well, nothing physically prevents a patient from being transferred, but. First of all, the hospital, Elmhurst, may not want to transfer the patient because there is revenue attached to every patient. Even a public hospital cares about maximizing its revenue. So the doctor and the nurse inside the hospital may want very much to transfer patient to Langone, but the administrator, the CEO of the hospital might not want to do that for financial reasons. So there is a problem on that end and then there's a problem on the other. And because NYU Langone, it's a private hospital and it wants to treat patients with private health insurance because that's going to bring the biggest profit. And the patient coming from Elmhurst, the public hospital is going to be a patient without private health insurance. So it's not a patient that NYU lingo and really wants anyway. So on both ends, Elmhurst may not want to transfer the patient and NYU might go, might not want to take the patient. So the incentives are not there for this. Very simple fix to work. That's right, because the incentive is profit. So at the end of the day, were there any transfers between the public and private hospitals, any meaningful number of transfers, there were less than 50. Wow. Doing the whole course of the pandemic, thousands of people in hospitals. There were less than 50 transfers from public hospitals to private hospitals. That is a genuinely shocking number. Yeah, and again, the transfers were wanted by the doctors and the nurses, but they didn't end up happening. I'm very rarely shocked. Yeah. So that brings us to the other possible solution with New York. Explored and actually poured a lot of money into which was the overflow hospitals, makeshift hospitals set up around the city that could take patients from these overburdened hospitals. But it turns out those didn't work either. We'll be right back. I'm Cardiff Garcia, the host of the new podcast, the next chapter by American Express business class. Each episode, I'll be sitting down with a best selling business author Angela Duckworth, welcome, Gladwell, thanks so much for being on the next chapter. Adam Grant, love you. Jay Jones, welcome. In revisiting their work, we'll also learn about what's inspiring them to write their next chapter. The next chapter by American Express business class is available anywhere you get your podcasts. My name is Dan Powell. I'm Marian lazano. We are composers at the New York Times and we write a lot of music for the daily. I'm currently working on a piece called geometry. It's a musical moment of reflection to help the Listener Digest the story. This piece is for a space episode. I want to put the listener right into the deep darkness of space. For this cue, the producers wanted us to write something that would evoke the late 70s. I started with a baseline and then I added some drums to it, he said. Can you, like, add 20 or 30% more funk to this? Yeah. We write music to highlight a moment, to draw you into the story without telling you how to feel. Yeah, it's always the puzzle to solve. So if you love the daily and you want us to keep making reflective, cosmic, sometimes groovy but always subtle music for the show. Support us by subscribing to the New York Times. Now as we all know, New York is the national epicenter of the coronavirus crisis. Now. It is all hands on deck there and the death toll in New York City from the COVID-19 pandemic has climbed to 450 with 26,000 testing positive so far. This is the naval ship comfort due to arrive in the area on Monday from Virginia in a field hospital. Brian. I remember these overflow hospitals really well. What we're doing here, the Javits Center is constructing 4 emergency hospitals. I remember Governor Cuomo walking through the Javits Center, this huge Convention Center. This was never an anticipated use. But you do what you have to do. That's the New York way. That's the American way on the West side of Manhattan, kind of showing off the hundreds of beds. I remember being little flowers on the sides of the tables next to the cots. And I know these were set up in each borough. So what happened that meant that they didn't actually do their job? Well, let's take the example of the Billie Jean King Tennis Center. Part of the Billie Jean King National Tennis Center right now is being converted into a temporary hospital. It's one of the biggest. And it's centers in the world. It's where the US Open is held. Some patients from nearby Elmhurst Hospital are expected to be transferred to the National Tennis Center Hospital. It was going to have 470 beds and hundreds of employees that were going to be available to take place in specifically from Elmhurst and Queens. This place will be a life saving place. It's going to help take the pressure off Elmhurst. It was supposed to be a crucial facility, but the first problem. That it had was bureaucracy. There were paperwork requirements. There were all kinds of orientations that the doctors needed to do training on the computer systems, training on the type of equipment that was going to be there and the paperwork that had to be filled out. And you had doctors in the middle of the peak of the pandemic, when people were dying, spending time doing things that had nothing to do with patient care. Another problem was that the hospital was suffering from a bit of an identity crisis about which types of patients it was going to treat, and at different points of time, even within the week that it was being set up. As of this morning, the complex was not likely to include COVID-19 patients. the US open is. City officials were changing their mind about that question this facility. To be able to take people from Elmhurst other coronavirus patients, bring them over here, relieve some of that pressure immediately, and they were conveying different directives to other hospitals about which types of patients they should be transferring to the Billie Jean King Tennis Center. And they ended up crafting a series of rules that were very restrictive about the types of patients that could go to Billie Jean King there were. Over 25 different exclusionary criteria, which is basically disqualifying conditions that if the patient has, they can't go to Billie Jean King. And one of them was just the fact that the patient had a fever, which is a hallmark symptom of the coronavirus. But at the same time, there were also a series of rules about the types of patients that they would not see because they would not severe enough. They were patients that were quarantining with the virus in hotels and in some cases ended up dying in those hotels. And when employees at Billie Jean King asked why they couldn't see and care for those patients, they were told that those patients aren't severe enough to be a Billie Jean King. So they couldn't see the really severe patients. They also couldn't see the patients that were not severe. And as a result, they didn't end up tweeting much of anybody. So did they see any patients? Well, hold on, because there's another problem and it relates to ambulances. So in the peak of the pandemic, if you were at your house and you called 911, the ambulance that arrived could not take you to Billie Jean King directly. The city had decided that ambulances would have to first take patients to a hospital, even if they're overburdened, and that hospital would triage the patient and then figure out where to send them. So Billie Jean King was really only taking transfers from other hospitals, but even the transferring process was blocked by ambulance regulations because there were situations where hospitals wanted to transfer patients. But there was no ambulance available to transfer them and Billie Jean King had its own ambulances on site. They could have gone to the hospital and picked up the patient. But the regular hospitals had exclusivity agreements with ambulance companies that said that nobody could pick up their patients. They could only send patients out in their own ambulances with these companies. And so that patient is just going to stay at Elmhurst and not get transferred to Billy Jenkin until. An ambulance from that company with the exclusive agreement is available. Yes. And that happened, so patients had to wait. OK. So back to that question. In the end, how many patients made it into this? Billie Jean King Overflow Hospital, 79. Jeez, that's 79. Throughout the course of the month that the Billie Jean King Center was open at any one time, there were maybe 20 or 30 patients there. So what were all the staff, the nurses, the doctors? At Billie Jean King Field Hospital Overflow Hospital, what were they doing? Well, in many cases, nothing. You know, I, I want to be clear because the doctors and nurses and other staffers that came to work in Billie Jean King, they came in many cases from around the country. They were experienced medical professionals and they really wanted to help and they were extremely well paid as well. They were paid the doctors, in many cases over $600. An hour. Wow. So they showed up to work ready to help, ego to help, but no patients came in the door. So I talked to some of them that said that in the peak of the pandemic, they were just sitting around on their phone all day. One of the workers of Billie Jean King, who I talked with, who was a nurse practitioner who came up from Baltimore. She said I basically got paid $2000 a day to sit on my phone and look at Facebook. We all felt guilty. I felt really ashamed to be honest. Right. Cause, like you said, they came to serve the public in New York in particular, a public that was trying to get into overburdened public hospitals. And here they are not able to do that because of exclusive ambulance agreements and kind of bureaucratic nonsense. That's right. Yeah. The facility ended up closing in early May, after the peak of the pandemic. There was really no need for it and ultimately for its work in treating 79 patients. So far, the city has paid the contract to about $52 million, but the bill is actually still coming in, and the total bill might actually be over $100 million. Brian, whenever we talk about inequality, it can feel like a very out of reach set of solutions, right, because almost by definition it is systemic, deeply rooted issues. But in the case of hospitals in New York, the solutions felt very practical and very simple. As you have laid them out, you know, cancel those exclusive ambulance agreements, transfer patients from public to private hospitals, they all seem quite within reach. Yeah, I think that's right. And. I think it's also important to note that even while the pandemic was going on, there were plenty of doctors and other hospital workers who noticed these inequalities and were trying to fix them. We talked with a number of doctors that actually rotated between working in the private hospitals and working in the public hospitals, and we're trying to raise alarms and even hospitals within the private networks trying to push their bosses. To do more to address inequalities, but. The reality was by that point the inequalities were so ingrained into the hospital system that there wasn't a whole lot that they could do. I think the story of what happened in hospitals in New York in the height of the coronavirus pandemic is really a story about. Officials and hospital executives and bureaucrats who? Accepted these inequalities in the system long ago. And. Have obviously known about inequalities for decades, but. Chose not to address them and found that they got exposed in this pandemic. But of course in that case. Isn't it the role of government? Isn't it the role of the mayor of New York City, the governor of New York? To not accept those kinds of inequalities and to do everything in their power to slice through that kind of complacency in the midst of a public health crisis. Yeah. And I think if you talked to the governor or the mayor, if you had them sitting here, they would say that they did as much as they could. And they did, suddenly. Spend a lot of money setting up field hospitals to help and set up a system to help with transfers. But one thing that I think is very telling is when I called the governor's office to ask why more patients would not transferred from overburdened hospitals to private hospitals that had open beds. The governor's office said that they accommodated every transfer that was requested by the hospitals. And they felt like that was their job. So they handled these requests, but they would not willing. To force hospitals to transfer, they were not willing to take that more fundamental step in changing the government's role. And I think it's because they themselves. Kind of accepted the reality as it was that they were going to be inequalities between different types of hospitals and different types of patients. Right to say that they processed every request they got for transfers to say like I caught a couple of the raindrops in this giant storm. But. What about that flood down the street, right? It's not addressing. The more fundamental problem. Brian, at the start of our conversation, you mentioned that peak hospitalizations are now occurring throughout much of the rest of the country. It's subsided in New York, but it's now happening in Texas. It's happening in Florida, it's happening in Arizona. I know that your investigation was into the hospitals in New York, but do we expect that what you saw in New York, these inequities, these private public hospital disparities that they are likely to play out across the rest of the country? There will definitely be disparities in every city in America. I think the question is whether other cities have learned from New York and are going to be willing to. Put in place systems and policies that can help balance out those inequalities in a more real way than we saw in New York. And I think that's still to be determined. Brian, thank you very much. We appreciate it. Thank you. On Sunday, the Times reported that the total number of infections in Florida has now surpassed that of New York, making the state the new epicenter of the pandemic. Florida has nearly 424,000 reported cases, compared with about 415,000 cases in New York. We'll be right back. What we owe the future is a new book written by Oxford philosopher William MacAskill. It offers a guide to making the future go better for future generations. Humanity's written history spends only 5000 years. The yet unwritten future could last for millions more, or it could end tomorrow. You can find out more about how to give future generations a world full of justice. Hope and beauty by learning more about this new book at what we owe thefuture.com. Here's what else you need to turn their day. The Times reports that the presence of federal agents in Portland galvanized thousands of people to join protests across the country over the weekend, reviving nationwide protests that had largely dissipated. One of the most intense protests was in Seattle, where a demonstration against police brutality turned violent after some protesters lit a detention center on fire, smashed windows and damaged a police building. In response, police declared the protest a riot, fired flash grenades, unleashed pepper spray and rushed into crowds, knocking people to the ground. That's it for the day. I'm Michael barbaro. See you tomorrow.